Payment while you are in PPR
Even if records are clean, between record submission, internal payer processing times, and auditor collaboration, payment on a claim that used to routinely take 21 days can sometimes take upwards of six months.
Pre-payment review
Pre-payment review delays your cash flow.
Insurance carriers that place a facility in PPR want to review medical records before they issue payment. Cipher maintains an in-house compliance department that runs that audit.
- Full EMR audit, a meeting with the clinical team, and contact with the assigned payer auditor
- Certified letters are often missed — Cipher can identify denial trends and contact SIU
- A dedicated C&R specialist reviews and submits records day to day
- Weekly deficiency review and a monthly update on passing rate and auditor feedback
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Speak with a compliance specialist
What a PPR is
An audit that happens before payment is issued.
A PPR is a pre-payment review. It is essentially an audit. Insurance carriers that place facilities into a PPR want to review medical records prior to issuing payment.
Typically a letter is issued via certified mail to the facility's mailing or servicing address. If the facility misses that notification — which is common — Cipher can identify payer denial trends on the claims-resolution side and contact the SIU (Special Investigations Unit) department for more information.
The cash-flow hit
PPRs delay cash flow. They also cut into margins.
There is no more direct way to say it. A facility now spends additional resources training the team and dedicating time to extra documentation — more labor than operations were built for.
Worse than delay
The facility does not get paid at all because the biller or clinical team did not know the required documentation guidelines.
How long a PPR lasts
Duration varies by payer and clinical quality.
That is a different question from how long a single claim takes to pay. PPRs themselves vary greatly based on both payer and clinical quality.
The payer often wants to see a passing rate of 80% or above, and they want the facility to maintain that rate at a volume relative to the claims that got them placed in audit. That is the payer's bar — not a Cipher guarantee.
Why facilities get placed
The most common reasons Cipher sees.
These are the reasons Cipher sees facilities placed in pre-payment review — not a complete list of every payer trigger.
- 01
Excessive OOS or exchange policies
A high share of out-of-state or marketplace exchange policies is one of the most common reasons Cipher sees facilities placed in PPR.
- 02
Negative routine medical-record denial trends
Repeated medical-record denials on routine claims — what Cipher calls negative routine MR denial trends.
- 03
Vague or generic coding processes
Vague or generic coding processes — one of the most common reasons Cipher sees facilities placed in PPR.
- 04
Excessive billing errors or claim patterns
Excessive billing errors, or billing patterns tied to frequent corrected claims or voided claims.
In-house compliance
Cipher keeps an in-house compliance department.
Cipher maintains its own in-house compliance department to stay up to date on insurance compliance standards — and to help Cipher's team and the facility's team stay up to date as well. When a new facility comes into a PPR, that department runs the work below.
When a facility enters PPR
Audit the EMR. Meet the clinical team. Call the assigned auditor.
A full audit of the EMR identifies the deficiencies that have to be addressed. Cipher meets the partner’s clinical team, presents the gaps, and provides context and tools to retroactively restore some records — and to put the right documentation in place immediately so future denials do not pile on. Cipher also contacts the assigned payer auditor to understand passing rate, the volume of records behind that rate, documentation pain points, and the auditor’s discretion.
Weekly and monthly
Weekly touchpoints. Monthly auditor feedback.
Each week, Cipher’s audit team reviews the prior week’s deficiencies, aligns on current documentation, and shares Cipher progress reports. Each month the facility gets the current passing rate, auditor feedback, and a chance to strategize.
Day to day
A dedicated C&R specialist owns the records.
A dedicated C&R specialist reviews and submits records as they come in, answers day-to-day questions, sits in the weekly checkpoints, and knows the PPR. When monthly auditor feedback lands, that specialist can push back on incorrect denial rationale, handle amendments and resubmission, and file appeals when they are available.
FAQ
PPR questions
What is a PPR?
A PPR is a pre-payment review. It is essentially an audit. Insurance carriers that place facilities into a PPR want to review medical records prior to issuing payment.
What are the most common reasons facilities get placed in a PPR?
The most common reasons Cipher sees are excessive out-of-state or marketplace exchange policies, negative routine medical-record denial trends, vague or generic coding processes, and excessive billing errors or billing patterns related to frequent corrected or voided claims.
How does a facility typically find out it is in a PPR?
Typically a letter is issued via certified mail to the facility’s mailing or servicing address. If the facility misses that notification — which is common — Cipher can identify payer denial trends on the claims-resolution side and contact the SIU (Special Investigations Unit) department for more information.
How long do PPRs last?
PPRs vary greatly based on both payer and clinical quality. The payer often wants to see a passing rate of 80% or above, and they want the facility to maintain that rate at a volume relative to the claims that got them placed in audit.
How does a PPR affect cash flow?
PPRs delay cash flow, and they reduce profit margins. The facility has to spend additional resources training the team and dedicating time to extra documentation — more labor than operations were built for. Even if records are clean, between record submission, internal payer processing times, and auditor collaboration, payment on a claim that used to routinely take 21 days can sometimes take upwards of six months. Worse than the delay is not getting paid at all because the biller or clinical team did not know the required documentation guidelines.
Talk with Cipher
Ask Cipher about a pre-payment review.
Cipher's in-house compliance department can audit the EMR, meet the clinical team, and work the assigned payer auditor. Call or send the facility details.
Request a PPR conversation
A specialist will follow up within 24 hours.